In September 2014, the American Physical Therapy Association published the Choosing Wisely list of “Five Things Physical Therapists and Patients Should Question,”1,2 in a partnership with the American Board of Internal Medicine (ABIM) Foundation. In April 2015, the ABIM Foundation instituted a new process that requires societies to affirm their lists on an annual basis. In response to this new requirement, APTA reconvened its original Choosing Wisely Work Group (Work Group) in May 2015 to review its list and determine if APTA should affirm or modify its 5 recommendations.
The Work Group consisted of APTA staff and staff-appointed physical therapist members representing a broad range of clinical expertise, practice settings, and patient populations. The Work Group was charged with (1) conducting a new literature search and review for Recommendation 1 (“Don't use passive physical agents except when necessary to facilitate participation in an active treatment program”), (2) reviewing the literature published since April 2014 for Choosing Wisely Recommendations 2 through 5, and (3) determining, based on the new literature, if each recommendation continues to reflect best evidence. Although the literature related to Recommendation 1 had not changed substantively, APTA decided that the list review process offered a good opportunity to clarify this recommendation for practitioners.
Since the 2014 publication of APTA's Choosing Wisely list, there has been some confusion about the interpretation of the terms “passive” and “physical agents” in Recommendation 1. In addition, because the Choosing Wisely list was developed before the current edition of the Guide to Physical Therapist Practice (Guide 3.0) was released, the use of the term “physical agents” in Recommendation 1 was not consistent with Guide 3.0 terminology. Guide 3.0 uses the intervention category “biophysical agents,” and many interventions included in this new category were not classified as “physical agents” in the previous edition of the Guide.
A new literature search was conducted using search terms based on the original intent of Recommendation 1 and classifications in Guide 3.0, such as “athermal agents” (eg, “pulsed electromagnetic fields”), “sound agents” (eg, “ultrasound”), and “thermotherapy” (eg, “heat”). After the Work Group reviewed the literature retrieved by the new search, the language of the recommendation was modified and agreed upon by all of the staff-appointed Work Group members. The Work Group members also reviewed newly published literature related to Recommendations 2 through 5 and determined that the recommendations continue to reflect best evidence.
The ABIM Foundation was informed that APTA had affirmed Recommendations 2 through 5 but had revised Recommendation 1 on APTA's list of “Five Things Physical Therapists and Patients Should Question,” as follows:
“Don't use (superficial or deep) heat to obtain clinically important long-term outcomes in musculoskeletal conditions.”
There is limited evidence for use of superficial or deep heat to obtain clinically important long-term outcomes for musculoskeletal conditions. Although there is some evidence of short-term pain relief for heat, the addition of heat should be supported by evidence and used to facilitate an active treatment program. A carefully designed active treatment plan has a greater impact on pain, mobility, function, and quality of life. There is emerging evidence that passive treatment strategies can harm patients by exacerbating fears and anxiety about being physically active when in pain, which can prolong recovery, increase costs, and increase the risk of exposure to invasive and costly interventions such as injections or surgery.
The references that will be posted on the Choosing Wisely site1 for Recommendation 1 include, but are not limited to:
Ulus Y, Tander B, Akyol Y, et al. Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: a randomized double-blind controlled clinical study. Int J Rheum Dis. 2012;15:197–206.
Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009;89:419–429.
Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001;81:1339–1350.
Graham N, Gross A, Goldsmith C, Michlovitz S. Heat and cold for neck pain: a systematic review. [Conference abstract] Physiother Can. 2009;61:73–73.
French SD, Cameron M, Walker BF, et al. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006;1:CD004750.
Gebremariam L, Hay EM, van der Sande R, et al. Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014;48:1202–1208.
Davis AM, MacKay C. Osteoarthritis year in review: outcome of rehabilitation. Osteoarthritis Cartilage. 2013;21:1414–1424.
Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;2:CD004258.
APTA will continue to review and affirm its “Five Things” list on an annual basis using a similar process. A Work Group composed of APTA members and appointed by APTA staff for their expertise in the topics on the list will be assembled each year. The Work Group will review newly published literature related to each recommendation and either affirm that the recommendations remain current or agree upon modifications to ensure that the list reflects best evidence.
You can find information about APTA's Choosing Wisely list at http://www.choosingwisely.org/societies/american-physical-therapy-association/ and on APTA's Integrity in Practice site at http://integrity.apta.org/ChoosingWisely/.
- © 2016 American Physical Therapy Association
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